Early in my career, I provided patient care at several community health centers in Washington, DC, and more recently, my wife served as the medical director for two area health centers. In fact, for several years we saw our own family doctor in a community health center. Despite the Supreme Court ruling that made the Affordable Care Act's expansion of Medicaid coverage optional for the states, health centers are expected to continue to play a big role in providing affordable primary care to millions of patients. And one of the many challenges that health centers encounter on a daily basis is how to arrange for patients to see subspecialists for diagnostic or therapeutic interventions (e.g., colonoscopy, surgery, cardiac stress testing) that their clinicians don't offer.
In a study published in Health Affairs, Katherine Neuhausen and colleagues asked directors of 20 community health centers in all parts of the U.S. how they addressed this challenge. The authors analyzed their responses to identify six distinct models that health centers use to obtain subspecialty care: Tin Cup, Hospital Partnership, Buy Your Own Subspecialists, Telehealth, Teaching Community, and Integrated System. As one might expect, health center directors who used the Tin Cup (i.e., begging subspecialists for charity care) model were least satisfied with their ability to access subspecialty care, while the most satisfied directors used the Integrated System model, which "features community health centers that are completely integrated with a local government health system or a safety-net hospital that has a comprehensive network of specialists." If a high-functioning community health center can provide its patients with a medical home, then the Integrated System represents the next essential step to meet all of their health care needs: the medical neighborhood.
In that neighborhood, it's important to recognize that the exchange of services can and should be a two-way street. Hospitals and large specialty practices have financial and material resources, while community health centers have the experience and know-how to manage care for high-risk patients with chronic conditions (the so-called "hot spotters" in Atul Gawande's widely read New Yorker article) who generate a disproportionate share of health care costs. The state of Maryland has been particularly innovative in encouraging these two types of organizations to combine forces through a matchmaking project whose results were outlined briefly in a JAMA article and further described in an innovations database maintained by Maryland's Department of Health and Mental Hygiene.
This post appeared on Common Sense Family Doctor in slightly different form on August 22, 2012.